What nursing diagnoses should be prioritized for an adult or geriatric patient with a terminal illness such as advanced cancer, end‑stage organ failure, or progressive neurodegenerative disease at the end of life?

Nursing Diagnoses for End-of-Life Goals

For patients with terminal illness at the end of life, prioritize nursing diagnoses that address physical symptom burden (pain, dyspnea, constipation), psychological distress (anxiety, depression, fear), impaired decision-making capacity, and caregiver strain, as these directly impact mortality, morbidity, and quality of life in the final phase of illness. 1, 2, 3

Primary Physical Symptom-Related Diagnoses

Pain Management

• Acute/Chronic Pain is the most critical diagnosis requiring immediate intervention, as uncontrolled pain significantly diminishes quality of life and should be assessed regularly 1, 2, 4
• Implement opioid therapy as the primary intervention, with morphine as the essential medication requiring careful titration based on symptom severity 2, 4
• For cancer patients specifically, combine NSAIDs, opioids, and bisphosphonates (particularly effective for bone pain in breast cancer and myeloma) 2, 4

Respiratory Compromise

• Impaired Gas Exchange/Dyspnea requires opioid administration for severe, unrelieved dyspnea in cancer and cardiopulmonary disease 1, 2, 4
• Provide oxygen therapy for short-term relief of hypoxemia in conditions like advanced COPD 2, 4
• A common pitfall is undertreatment due to unfounded concerns about respiratory depression from opioids—evidence supports their safety when appropriately dosed 4

Gastrointestinal Function

• Constipation ranks among the most frequently recorded nursing diagnoses in terminally ill cancer patients receiving home care 3
• Address proactively as opioid therapy intensifies, as this is a predictable consequence of pain management 3

Psychological and Emotional Diagnoses

Mood Disturbances

• Anxiety and Depression must be assessed regularly in all patients with serious illness 1, 2
• For cancer patients with depression, use tricyclic antidepressants, selective serotonin reuptake inhibitors, or psychosocial interventions 1, 4
• Fear related to death and dying requires nurses to permit verbalization of anxieties and offer consistent empathy, acceptance, and warmth 5

Coping Mechanisms

• Ineffective Coping should be addressed through rapport building, exploration of illness understanding, and assessment of coping needs 1
• Spiritual pain associated with dysfunctional coping strategies affects a significant proportion of patients and caregivers 1

Decision-Making and Communication Diagnoses

Advance Care Planning

• Deficient Knowledge regarding prognosis and treatment options must be addressed early—ideally within 8 weeks of diagnosis of advanced disease 1, 2
• Initiate conversations about preferences for end-of-life care early in the course of incurable illness and readdress periodically based on clinical events 1, 2, 4
• Ensure completion of advance directives for all patients with serious illness 1, 2, 4

Prognostic Awareness

• Decisional Conflict arises when patients lack clear understanding of their illness trajectory 1
• Provide information in small amounts using language appropriate to the patient's educational level and health literacy 2
• Verify comprehension frequently and acknowledge emotions throughout conversations 2

Functional Status Diagnoses

Activities of Daily Living

• Self-Care Deficit becomes increasingly relevant as disease progresses 6
• Fatigue significantly impacts quality of life and requires assessment as part of comprehensive symptom management 1
• Document functional status changes as these inform prognosis and treatment decisions 1

Caregiver-Related Diagnoses

Family Burden

• Caregiver Role Strain requires routine and periodic screening for practical and emotional needs 2, 4
• Provide support including listening to concerns, attention to grief, and regular updates about the patient's condition 2
• Identify family members at risk for complicated bereavement 7

Family Coping

• Compromised Family Coping should be addressed through education about the dying process and permission to participate in comfort measures 7, 5
• Allow and encourage family members to be with the patient 4, 5

Dignity and Spiritual Diagnoses

Existential Concerns

• Spiritual Distress requires pastoral care intervention to identify and address unmet spiritual needs regarding meaning, self-worth, and relationship reconciliation 1
• Hopelessness can be mitigated through legacy work, meaningful tasks, and helping patients explore new goals and priorities 1

Loss of Dignity

• Risk for Compromised Human Dignity encompasses illness-related concerns, dignity-conserving repertoire, and social dignity inventory 6
• Provide culturally sensitive and respectful treatment that honors the patient's values and preferences 7

Critical Implementation Considerations

Assessment Approach

• Use multidimensional methods for assessing patients' real needs, as nurses' assessments show only 63% congruence with patient-reported symptoms 3
• Agreement is more frequently found with somatic symptoms than psychological ones, requiring extra vigilance for emotional distress 3

Timing of Interventions

• Early palliative care involvement (within 8 weeks of diagnosis) improves quality of life and mood 1
• Sentinel events that should trigger reassessment include: ICU admission, mechanical ventilation initiation, CNS metastasis diagnosis, new chemotherapy regimen, major surgery decisions, and gastric tube placement 1

Common Pitfalls to Avoid

• Do not reduce opioid doses solely for decreased blood pressure, respiration rate, or level of consciousness when necessary for adequate symptom management at end of life 4
• Avoid nurse avoidance behaviors such as focusing only on technical tasks, directing conversations away from dying, or unnecessarily overmedicating patients 5
• Do not assume psychological symptoms are less important than physical ones—both require equal attention 3